Disability insurance benefits are meant to replace lost income in case of an accident or illness that prevents you from working. New York Life Insurance Company’s portfolio of disability insurance products includes long term disability insurance for individuals, as well as group disability products for employers. However, disability insurance companies such as New York Life do not always pay disability insurance benefits as they should and legitimate disability claims are frequently denied.
If you are looking for a disability attorney who fights back against New York Life disability denials, contact us today for a free disability case evaluation. Call us at (888) 321-8131 to get help with your claim.
Top Reasons for New York Life Disability Claim Denials
There are many reasons why New York Life Insurance Company may have denied your long term disability claim, so you will have to review your denial letter to determine the specific reason for New York Life’s denial of your claim. If you’re still not sure, a disability attorney can help you understand why your claim was denied.
Reasons for denial include, but are not limited to:
- Insufficient medical records;
- Insufficient objective medical evidence;
- A non-verifiable medical condition
- Your doctors did not return the Attending Physician Statement;
- A Peer Review Physician does not agree with your doctor;
- You exaggerated symptoms to qualify for benefits;
- Video and social media surveillance;
- You missed a deadline;
- You are disabled due to pre-existing condition;
- You are disabled due to a specifically excluded condition;
- You do not meet the definition of disability in the policy;
- There has been a change in the definition of the term disability; and
- You are only partially disabled.
Next, we’ll dig deeper into some of the policy provisions and limitations behind some of the most common reasons for claim denials:
You Do Not Meet the Definition of Disability
New York Life will deny your claim for benefits if it determines that you do not meet the definition of disability as stated in your policy. The following is an example from a New York Life disability insurance policy.
Covered Total Disability – A Covered Total Disability is an incapacity from the following which an Insured Person suffers while he or she is insured under the Policy:
1. an Illness, but only if such incapacity completely and continuously prevents the Insured Person from doing the material and substantial duties of his or her occupation, provided he or she is not engaged in any occupation for pay or profit; and
2. an organ donation by an Insured Person, if he or she has been continuously insured under the Policy for at least 6 consecutive months on the day of such donation.
You Have a Pre-Existing Condition
Most insurance companies include a pre-existing condition limitation in their policies. The following is an example from a real New York Life policy:
Preexisting Condition means an Illness or any condition related to such Illness for which a person consults a doctor, receives medical services or supplies or takes any medication during the 12 month period immediately before the Insured Person’s Certificate Effective Date, if such Illness or condition is not fully disclosed when a request for initial insurance is made under the Policy.
Preexisting Condition does not include: (a) any such Illness or condition for which such person has not consulted a doctor, received medical services or supplies or taken any medication for a continuous period of 12 consecutive months after the date he or she first becomes an Insured Person; (b) any such Illness or condition after such person has been continuously insured under the Policy for 24 months; or (c) an Illness or condition classified as an Impairment Restriction.
Many insurers apply the pre-existing condition limitation inappropriately as a way to deny claims. If you were denied based on the pre-existing condition limitation, you should seek legal advice. Our team has extensive experience defending disability claims that were wrongfully denied by their insurer due to a pre-existing condition limitation.
You Have a Mental Disorder and/or Chemical Dependency
Your claim may be approved initially, but most policies will only pay benefits related to a mental disorder or chemical dependency for a limited period of time. Here is an example from a New York Life policy:
The Maximum Benefit Period for all Covered Disabilities of an Insured Person which are due to or related to Mental Disorders and/or Chemical Dependency while such person is insured under the Policy, whether insurance has been continuous or interrupted, cannot exceed the lesser of: (a) 36 months; or (b) the Maximum Benefit Period for a Covered Total Disability.
This limitation does not apply to any period during which such Insured Person is institutionalized.
“Mental Disorder” means a condition due to or resulting from psychiatric or psychological conditions, regardless of cause, such as: (a) schizophrenia; (b) depression; (c) manic depressive or bipolar illness; (d) anxiety; (e) personality disorders; and/or (f)
adjustment disorders or other conditions, usually treated by a mental health provider or other qualified provider using psychotherapy, psychotropic drugs or other similar modalities used in the treatment of the above conditions. This limitation does not apply to dementia, if due to: (a) stroke; (b) trauma; (c) viral infection; (d) Alzheimer’s disease; or (e) other conditions not listed above which are not usually treated by a mental health provider using psychotherapy, psychotropic drugs, or other modalities.
“Chemical Dependency” means the abuse of or psychological or physical dependency on or addiction to alcohol or a controlled substance. For purposes of this definition, “controlled substance” means a toxic inhalant, a volatile chemical, abusable glue or aerosol paint, or a substance designated as or considered a controlled substance under applicable federal, state, or local authority.
The policy excerpts above are sourced from a real New York Life long term disability insurance policy.
What to Do After a Claim Denial
Despite the promises made when pushing their insurance policies, New York Life frequently denies claims for disability benefits. If your claim is denied you should receive a written copy of the decision by email or in the mail. The written decision should state the reasons New York Life denied your claim, inform you about your right to file an appeal, and state the deadline by which you must submit your appeal to New York Life.
After receiving your denial letter, you should also request a copy of your claim file and your disability insurance policy. You will need your claim file to review all of the information that was available for review when New York Life denied your claim. This includes your medical records, claim forms, and any other evidence New York Life obtained while reviewing your claim. You also need your policy, as it is the contract that governs your claim.
How to File an Appeal with New York Life Insurance Company
Fortunately, a claim denial is not the end of the road for policyholders. The type of disability insurance policy you have will dictate whether it is governed by ERISA disability law and the process you have to go through to recover your benefits.
- Group Disability Insurance Policies: If you have a New York Life disability policy that was obtained as part of a group benefits plan, your policy is likely governed by ERISA. ERISA disability insurance claims have strict appeal procedures and deadlines that you must adhere to. Under ERISA disability law, you are required go through the administrative appeal process before you can file a lawsuit against the insurer that denied your claim. You only get 180 days to appeal. If you do not file the required appeal within the designated time frame, then you will not be able to take legal action against the insurer.
- Individual Disability Insurance Policies: Individual disability insurance claims and policies are not governed by ERISA. If you have an individual disability policy and your disability insurance benefits are denied or cut off prematurely, you may not have to file an administrative appeal to enforce your rights. In fact, you may be able to proceed directly to filing a lawsuit against New York Life Insurance Company. However, it may still be beneficial to appeal. You should request a free consultation with an experienced disability attorney to determine your legal rights and the best way to obtain your long term disability benefits.
Whether you have a group policy or an individual policy, we encourage you to check out our free step-by-step guide to appealing a disability insurance claim denial. The guide includes templates to appeal, request more time, and to request your files from the insurance carrier and your health care providers. You will also receive residual functional capacity forms for your doctors to fill out in support of your claim.
How a New York Life Disability Attorney Can Help
If your long term disability claim was denied by New York Life, we can help you recover the benefits that are rightfully yours. We are not afraid to take on New York Life or any other major disability insurance companies.
Our disability law firm offers a free disability policy review and consultation for those whose long term disability claims have been denied. Nick A. Ortiz and his experienced legal team are experts in disability law and offer the following services:
- Appeal of a denial of individual or government disability benefits from New York Life;
- ERISA appeal of a New York Life Insurance Company denial of group disability claim;
- Appeal of a New York Life wrongful termination of individual or government long term disability insurance claim;
- ERISA appeal of a New York Life Insurance Company wrongful termination of group long term disability benefits;
- Filing a lawsuit against New York Life after final denial of individual or government disability claims;
- Filing an ERISA lawsuit against New York Life after final denial of group disability benefits; and
- Lump-sum buyout or settlement of New York Life long term disability policies in lieu of New York Life’s monthly long term disability insurance benefits payments.
We do not typically handle all short-term disability claims, but if you have a long term disability claim that will also be affected, we may be able to help with both your short-term disability and long term disability insurance claims.
What About New York Life Group Benefit Solutions Claims?
In 2020, New York Life Insurance Company acquired Cigna Group Insurance’s group life, accident, and disability insurance business, and rebranded it as New York Life Group Benefit Solutions. The acquisition added more than 9 million customers to New York Life’s business portfolio, making it one of the largest carriers of group disability insurance.
We have experience with both New York Life and Cigna Group Insurance claims, so the acquisition will not impact our ability to help claimants fight back against wrongful long term disability insurance claim denials and terminations issued by New York Life Group Benefit Solutions
What If I Also Need to Apply For Social Security Disability Benefits?
It is not unusual for disability insurance companies to require disabled individuals to file a claim for Social Security Disability (SSD) benefits. This is because, under the terms of most insurance policies, the insurer can reduce the amount they pay you each month by the amount of the SSD benefits you receive.
If New York Life is requesting that you file for SSD benefits, we can assist you with that claim as well. Much of the medical evidence used to support your disability claim with New York Life can also be used to support a claim with the SSA, so it often makes sense to hire one disability attorney who can handle both claims.
Request a Free Consultation with a Disability Attorney Specializing in New York Life Cases
The Ortiz Law Firm specializes in disability claims with insurance carriers like New York Life and helping the disabled receive the pay they deserve. If your disability case has been denied by New York Life, the experienced legal team at our law firm can help. We will review your claim to determine your next step in the process, and we will not rest until we have recovered the disability insurance benefits you deserve.
Let us help get your claim approved. Call us today at (888) 321-8131 to request a free consultation with a New York Life disability attorney. We will evaluate the specifics of your New York Life disability insurance claim to determine how we can assist you in obtaining the benefits you deserve.